What is Constipation
Most healthy people have 1-2 bowel movements a day, 1-2 times a day, with formed or soft stools. In a few healthy people, the frequency of bowel movement is 3 times a day or once every 3 days, and the stool is semi-formed or salami-like hard stool. Typically, constipation is defined as a decrease in the number of bowel movements, difficulty in elimination or poor elimination. Chronic constipation can be considered if these symptoms occur continuously or intermittently for 3 of the past 12 months. Previously, the understanding of constipation was limited, and it was not considered an independent disease, but a symptom of multiple diseases. Therefore, treatment usually focused on treating symptoms, resulting in incomplete treatment, with patients taking medication for years, and stubborn constipation occurring during or after stopping medication. In recent years, with the advancement of research, constipation has gradually been included as an independent disease in the scope of treatment, and the International ROMA Conference specifically formulated the diagnosis and treatment standards for constipation, classifying constipation as a functional gastrointestinal disease, and suggesting that countries around the world should develop a diagnosis and treatment process that takes into account their national conditions. The “Guidelines for the diagnosis and treatment of chronic constipation in China 2002-8” formulated by the Gastrointestinal Dynamics Group of the Chinese Society of Gastroenterology classifies constipation into three degrees: mild, moderate and severe. Mild refers to symptoms that are mild, do not affect life, and can be improved with general treatment without medication or with less medication. Severe refers to constipation symptoms persist, the patient is in unusual pain, seriously affects life, can not stop medication or treatment is ineffective. Moderate is in between. So-called refractory constipation is often severe constipation, which can be seen in outlet obstructive constipation, colonic weakness, and severe constipated irritable bowel syndrome (IBS). Currently, advanced research and advances in therapeutics have made it possible to surgically treat some previously refractory constipation with excellent outcomes, which has been a boon to patients. In particular, our hospital pioneered PPH for outlet obstructive constipation, which is simple to operate, less painful for patients, and has obvious efficacy, has accumulated a large number of cases, and the examination and treatment are becoming more and more mature. In addition, with the progress of pharmacology, the application of oral laxatives is becoming more standardized and mature, and the previous habit of abusing and using laxatives indiscriminately has been abandoned. The examination methods are objective, following evidence-based medicine, no longer diagnosed by the subjective judgment of the patient and the examiner, and at the same time can make judgments about the efficacy.
What kinds of constipation are there?
Constipation is mainly divided into slow transmission type, exit obstruction type and mixed type. Irritable bowel syndrome (IBS) type constipation is a type of constipation associated with abdominal pain or bloating, and has all three of these characteristics simultaneously or separately.
Etiology of chronic constipation
Chronic constipation has both functional and organic causes. Specifically, the following.
1, intestinal tumor, inflammation or other causes of intestinal lumen narrowing or obstruction.
2, rectal and anal diseases: rectal intra-mucosal prolapse, rectal prolapse, puborectalis syndrome, pelvic floor descent syndrome, pelvic floor spasm syndrome, isolated rectal ulcer syndrome, anal fissure, etc.
3.Endocrine or metabolic diseases: diabetes mellitus, hypothyroidism, parathyroid disease, etc.
4, neurological diseases: central encephalopathy, stroke, multiple sclerosis, spinal cord injury and peripheral nerve diseases, etc.
5.Intestinal tube muscle or neuron lesions.
6, colonic neuromuscular lesions: pseudo-intestinal obstruction, congenital megacolon, etc.
7, mental and psychological disorders.
8, drug factors: aluminum, iron, opioids, antidepressants, anti-Parkinson’s disease drugs, calcium antagonists, diuretics and antihistamines, etc.
What to check for constipation
In addition to history taking, physical and instrumental examinations are essential. In specialized anorectal centers, there are many examination items, many of which are not well understood by the patient. These items can provide an objective basis for the causes of constipation and guide targeted treatment.
1.Anorectal diagnosis: to understand the function of the anal sphincter, the presence of anal stenosis, fecal impaction, the presence of rectal protrusion, rectal mucosal prolapse, the presence of rectal tumors, etc.
2, rectosigmoidoscopy: observe the morphology of intestinal mucosa, whether there is inflammation, tumor, etc.
3.Gastrointestinal passage test (large intestine transmission test): patients are given oral non-passage X-ray markers, and abdominal plain films are taken at 24, 48 and 72 hours to calculate the discharge rate in order to assess whether the large intestine transmission function is normal. Usually, 80% elimination at 72 hours is considered normal. Less than 80% is slow transmission, which can cause constipation.
4, defecography: the most important method to check the exit obstruction type constipation. Dilute barium and simulated material line enema, dynamic observation of the functional changes of the anus and rectum in the process of defecation under X-ray, to provide an accurate objective basis for rectal protrusion and rectal mucosal prolapse.
5.Anorectal manometry: commonly used as an enema, it can detect the resting pressure of the internal anal sphincter, systolic pressure of the external anal sphincter, rectal compliance and recto-anal inhibition reflex (RAIR). This test fully assesses anorectal function in detail, and for patients with exit obstruction constipation, this test can be performed before surgery to generally evaluate the postoperative effect.
6.Balloon expulsion test: A balloon is placed in the rectum, inflated or filled with water to simulate feces, and the subject is examined for expulsion, and the test is positive for exit obstruction.
7.Electromyography: converting muscle activity into electrical signals can clarify whether the lesion is myogenic.
What is slow-transmission constipation of the large intestine
Slow-transmission constipation is often characterized by low bowel movements, reduced stool frequency and hard, dry stools. The main cause is the slowing down of the transport function of the large intestine and the prolonged stay of the stool in the large intestine, which is more complicated and more common in the elderly.
What is outlet obstruction constipation?
Exit-obstruction constipation is often characterized by difficulty in emptying the rectum, a feeling of obstruction, and a sense of incomplete stool. It is the most common type of constipation. The incidence is higher among middle-aged and elderly people and women. In recent years, with the change of lifestyle and diet, it is also common among young people. The main causes of outlet obstruction constipation are rectal prolapse, rectal prolapse and puborectal muscle syndrome.
What is prolapse of the rectum
Anterior rectal protrusion refers to the weakness of the rectovaginal septum, which is squeezed by stool during defecation, resulting in the bulging of the anterior rectal wall toward the posterior vaginal wall, also known as posterior vaginal bulge. Patients have a strong sense of incomplete stool, which is common in menstruating women. Patients need to press the posterior vaginal wall to assist in defecation, which is often used as a clinical indication for surgery. Patients with anterior rectal prolapse often have varying degrees of internal rectal mucosal prolapse.
What is endorectal prolapse?
The common symptoms of endorectal mucosal prolapse are difficulty in emptying the rectum, a sense of incomplete stool, and a sense of obstruction, characterized by a stronger sense of obstruction the harder one strains. Most patients often have psychiatric symptoms such as depression and anxiety.
What is puborectalis syndrome
Puborectal muscle syndrome is one of the causes of outlet obstruction constipation and includes hypertrophy and spasm of the puborectal muscle. It often causes irregular bowel movements, progressive defecation difficulties, anal swelling discomfort and pain, which can cause great pain and mental stress to the patient, and the efficacy of medication is mostly unsatisfactory, often requiring surgery or biofeedback treatment.
What is isolated rectal ulcer syndrome
Patients with intra-rectal mucosal prolapse will have bleeding spots and ulcers on the rectal mucosa based on long-term forceful defecation, which will aggravate exit obstruction constipation, thus forming isolated rectal ulcer syndrome.
What is irritable bowel constipation
Irritable bowel syndrome (IBS) is a common functional disorder of the intestinal tract that manifests as alternating diarrhea and constipation. It is often accompanied by clinical abdominal pain and bloating.
How constipation is diagnosed
The first step is to take a detailed medical history, which is very important. This includes symptoms of constipation, duration of the disease, gastrointestinal symptoms, concomitant symptoms and diseases, as well as medications used in the past, recent examinations, and the presence of psychiatric disorders. The next step is to perform an instrumental examination. For example, rectosigmoidoscopy should be performed to exclude tumor and inflammation, colonic transmission test should be performed to clarify whether there is slow colonic transmission, fecal imaging should be performed to clarify whether there is outlet obstruction, and anorectal manometry should be performed to clarify whether sphincter function and normal pelvic floor reflex exist. After a series of tests, the cause of constipation can be identified and the treatment can be tailored to it.
What are the ROMA (Rome) criteria for constipation?
The ROMA criteria are the international consensus for the diagnosis and treatment of functional gastrointestinal disorders, and the international standards for ROMA I, II and III constipation were established by the International ROMA Collaborative Committee in 1988, 1999 and 2006 respectively.
What types of laxatives are there and what are their characteristics?
1, stimulating laxatives, mainly with stimulation of the large intestinal wall to promote peristalsis. Mainly diarrhea leaves, rhamnolipids, phenolphthalein, castor oil, etc., long-term use of stimulant laxatives can damage the patient’s enteric nervous system, and is likely to be irreversible.
2, volumetric laxatives, mainly to make the intestinal content osmotic pressure rise, the water from the tissue inhaled into the intestinal lumen, so that the intestinal content volume increases, stimulating the intestinal lumen pressure receptors, causing an increase in intestinal peristalsis, producing laxation. Such as magnesium sulfate, mannitol, etc.
3, lubricating laxatives: intestinal absorption is not digested, only play a lubricating effect on the intestinal wall and stool both, and can prevent water absorption, softening stool, solve defecation difficulties. Paraffin oil, glycerin, lactulose, etc.
4, swelling laxatives, can accelerate the colon or the whole gastrointestinal transit, adsorption of water, so that the stool is loose and easy to discharge, such as gum, plantain, oat bran and other soluble cellulose.
5, new laxative, polyethylene glycol PEG, such as Fosone, a new drug for the treatment of chronic constipation newly marketed at home and abroad in recent years. The mechanism of action of Fosone is to combine the water in the intestinal cavity through hydrogen bonding, softening the stool and preventing constipation, which does not affect the colon transit time, neither is it degraded in the intestine, nor does it produce organic acids or gases, does not change the acidity or alkalinity of the stool, does not affect the pH of the intestine, and does not change the normal flora of the intestine, so it is relatively an effective drug with good safety.
Which laxatives should not be taken for a long time
Generally speaking, laxatives should not be taken for a long time, as they are easy to form dependence. Especially stimulating laxatives, long-term use of anthraquinone-based laxatives such as senna, aloe vera, rhubarb, etc. can also lead to the formation of colorectal melanosis.
How to use oral laxatives correctly
The selection of inappropriate laxatives or unreasonable doses of laxatives may cause adverse reactions such as dehydration, electrolyte balance disorders, dependence, and blackening of the colon. For patients with hypertension, heart disease, diabetes and renal insufficiency combined with constipation, safe laxative drugs such as polyethylene glycol (Fosamax) should be used.
What is colorectal melanosis?
Nigrosis of the colon is a non-inflammatory, benign, reversible lesion characterized by hyperpigmentation. The cause is still not well understood, but it is generally believed that the lesion is associated with the long-term use of anthraquinone-based laxatives, including senna, Pocahontas, aloe vera, and rhubarb, and that the degree of melanosis is proportional to the duration and total amount of anthraquinone-based laxatives taken. The incidence of colorectal polyps and tumors is high in patients with colorectal melanosis, and some of them have cancerous potential.
What to do after discovering melanosis of the colon
Patients should stop and reduce the consumption of anthraquinone laxatives, which is reversible, and the intestinal mucosa will gradually return to normal after the drug is stopped.
How to correctly use laxatives topically
Topical laxatives such as cathartic (containing magnesium sulfate, glycerin and propylene glycol) can lubricate and stimulate the intestinal wall, soften the stool and make it easy to pass, 20ml/time for adults. It is mainly used for patients with hard stools, especially for elderly patients. Because it is irritating and also easy to form dependence, it is recommended that elderly people should not use it for a long time. After use, if you can rest for a moment in the prone position, the effect will be significantly improved.
How to treat slow transmission constipation
First of all, general treatment, reasonable diet, increase dietary fiber content, increase water intake, strengthen exercise, and develop good bowel habits. Secondly, rational medication, less use of irritating laxatives such as sulfate and anthraquinones, recommended application of volumetric laxatives such as Fosone and other polyethylene glycols, finally, surgery should be cautious, partial and subtotal resection of the large intestine long-term efficacy is uncertain, total resection of the colon (preserved or not preserved cecum) rectal anastomosis, efficacy is certain, but many complications, generally difficult for patients to accept.
How to treat outlet obstruction type constipation
General and pharmacological treatment is the same as that for slow-transmission constipation of the large intestine. There are many surgical methods for outlet obstruction type constipation. Traditionally, for internal rectal mucosal prolapse, there are rectal mucosal sleeve debridement (Delorme), rectal mucosal columnar suture fixation, rectal mucosal collar ligation, rectal mucosal sclerotherapy injection, etc. The main procedure for proctal protrusion is transrectal or vaginal protrusion repair. These procedures are characterized by poor long-term efficacy and easy recurrence. In recent years, with the application of PPH surgery, good results have been achieved in the treatment of outlet obstruction type constipation, and its operation is simple, the patient suffers little pain, and the efficacy is obvious, and a large number of cases have been accumulated in our hospital.
How to treat irritable bowel constipation
Irritable bowel constipation is often associated with abdominal pain and bloating, and is usually treated with diet and medication. In case of combined outlet obstruction constipation, surgical treatment may be indicated.
Biofeedback treatment for constipation
Biofeedback therapy has been applied to the clinical treatment of constipation in recent years, and advanced biofeedback therapy instruments have appeared in China and internationally. Its treatment mechanism is different from traditional drug and surgical treatment. With the help of biofeedback therapy instrument, patients can see their own muscle activity signals, so as to gradually regulate muscle activity and restore normal function. The effect of biofeedback therapy on the sphincter is to use the feedback stimulation of sound and image to train the patient to correctly control the stretching and contraction of the anal sphincter, to increase the amplitude of the contraction of the external anal sphincter, to decrease the amplitude of its relaxation, to make the fluctuation of the internal sphincter potential disappear, to increase the frequency and amplitude of the external sphincter potential, to accelerate the peristaltic movement of the colon to promote the downward movement of the fecal mass, to expel the feces, and to effectively eliminate the contradictory movement In addition, it can make all muscle groups of pelvic floor move in a coordinated manner during defecation, stimulate and establish normal defecation reflex to achieve normal defecation. Biofeedback therapy not only affects the condition of the pelvic floor muscles but also affects the brain’s regulation of bowel function through neural pathways, such as changing the transmission of the gastrointestinal tract and rectal sensitivity. As a new treatment, biofeedback is a better treatment for patients with complex constipation because it is non-surgical and non-invasive.